Should MIPS Be Saved? Depends on Who You Ask

Opinions vary among expert panel on the Medicare reimbursement program

WASHINGTON -- Medicare's Merit-based Incentive Payment System (MIPS) for physician reimbursement has serious flaws -- but whether it should be saved is open to debate, as seen at a Brookings Institution briefing on the topic.

"I would argue there is still some value in the program. The intent of program is really to streamline and tie together some existing, very disparate programs that were out there," Shari Erickson, MPH, vice president of governmental affairs and medical practice at the American College of Physicians, said at the Friday briefing.

She noted that when her organization does quality improvement projects with its members, "They work well. When you implement them well, that may mean that physicians, clinicians, staff may have to do extra steps ... but they don't generally mind that, because they see it's meaningful to themselves and their patients. So how can we translate what we're learning there to the MIPS program? How can we get rid of [measures] that are not good measures and also [address] specialists who aren't having enough? I think we really have to think through how to do this and be courageous about it."

A Lack of Evidence

But Matthew Fiedler, PhD, a fellow at the Schaeffer Initiative for health policy at the Brookings Institution, a left-leaning think tank, disagreed. First of all, "the empirical evidence on value-based purchasing and 'Pay for Performance' programs ... is just very weak," he said. In addition, "the small numbers [problem] is just fundamental here. When you're trying to do clinician- or practice-level quality measurement, you're going to have very noisy measures. So the amount of 'incentive kick' you're getting for the amount of risk you're exposing providers to is not a very attractive tradeoff."

In addition, the "scattershot" nature of the incentives provided "makes it hard for providers to figure out how to respond to them," said Fiedler. "If we have a structure we think is unlikely to work -- based on prior experience with problems we can't fix -- it's not cost effective to continue to operate this program."

MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and Meaningful Use into one single program based on quality, resource use, and clinical practice improvement. Under MIPS, doctors earn a payment adjustment based on evidence-based and practice-specific quality data that they report to the Centers for Medicare & Medicaid Services (CMS).

Administrative Complexity

Tim Gronniger, MPP, senior vice president of development and strategy at Caravan Health, which helps health systems create and operate accountable care organizations, was also a "no" on continuing MIPS. "I think MIPS can't be made to work to accomplish the objectives Congress made out for it," he said. "It's a very administratively complex and difficult-to-manage program from [the view of] the practice administrator." Instead of motivating practices to figure out what services patients needed, "I heard [from them] that it [most often] incentivized the choice of the easiest measures."

"MIPS allows physicians to choose the measures on which they're judged, and while there are a huge number of measures to choose from, some specialists say there aren't enough in their specialty," Gronniger said. "Clinicians [often] gravitate toward the easiest measures," with the number one measure being documentation of medications in the record -- something that in many cases is already a state law requirement. "[Medicare] is aware of this and is trying to rotate out topped out measures, but for reasons of economy, it's hard to do in a sustainable way over time."

As for the small numbers problem, some of the measures included in MIPS require a minimum threshold of 10 or 20 cases per year, which is "going to be hard to justify in terms of [whether] that's a good measure of a clinic's performance," said Gronniger. "It's not something that's going to be solved with statistics or trying harder; it's an intractable problem, something that can't actually be fixed by simply tinkering ... From my perspective, it's much better for Congress to get involved now and greatly simplify the program, and to forget about connecting a small list of measures to large payment adjustments."

One Health System's Experience

The audience also heard from Valinda Rutledge, MBA, vice president for public payer strategy at Greenville (S.C.) Health System, which had its own experience implementing MIPS. About 32% of Greenville's practices in its clinically integrated network are in rural areas, she noted.

The system's absence of a risk adjustment mechanism "is not addressing the older and sicker population that you currently see in a rural area," Rutledge said, adding that although smaller practices get a slight bonus, "it doesn't level the playing field in the competition between rural and urban practices."

In addition, "rural providers have been running lean for decades and simply don't have enough staff to address MIPS's complexity," she said, noting that the typical facility has one or two physicians and similar numbers of mid-level providers, as well as part-time office staff. But the worst part is that the money gained by participating in MIPS doesn't justify the money spent on the program.

"We spent a lot of energy giving [our providers] extra resources -- we hired staff, spent time side by side with their practices, and we would go into practice and sit down with all members of their teams. We hired dozens of full-time staff ... to provide support and resources to meet MIPS requirement," Rutledge explained. "We did so well, we got close to 95% when we got our MIPS score back ... We were all very happy until we realized that it gave us a 1.59% payment bonus, and that included an exceptional performance bonus." That amount equated to 60 cents for every dollar they spent, she said.

"That's not sustainable going forward," Rutledge added. "So what should be our next step; do we stay in MIPS? We decided that MIPS has to be the next step in looking at competency for getting into an advanced alternative payment [APM] model."

For its part, Congress is not really talking about dismantling MIPS at this point, said Sarah Levin, a member of the minority staff on the House Ways & Means Committee. "MIPS is a bipartisan solution that came after a decade of short-term patches," said Levin, who was speaking only for herself. "This is Year 2 of the program; we don't even have results from 2017 ... [and penalties don't start] till 2019."

"We don't know how the program is working," she said. "Congress has invested in making sure it works and can be useful. We made some technical changes in the Bipartisan Budget Act providing more flexibility to physicians, and more time to on-ramp and clarify terms [physicians found confusing]."

"The physician community and patient community are not banging on the door to repeal MIPS -- they're saying, 'I need an advanced APM; how can I get one?' " she added. "That's a good conversation to have."

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